Provider Demographics
NPI:1033684782
Name:ECCLES, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ECCLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8334
Mailing Address - Country:US
Mailing Address - Phone:801-589-9463
Mailing Address - Fax:
Practice Address - Street 1:74 E 11800 S STE 360
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-260-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8695231-1206363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program